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Escobar-Domingo MJ, Bustos VP, Akintayo R, Mahmoud AA, Fanning JE, Foppiani JA, Miller AS, Cauley RP, Lin SJ, Lee BT. The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis. Microsurgery 2024; 44:e31203. [PMID: 38887104 DOI: 10.1002/micr.31203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 04/03/2024] [Accepted: 05/24/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction. METHODS A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection. RESULTS A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2. CONCLUSION The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.
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Affiliation(s)
- Maria J Escobar-Domingo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Miami, Miami, Florida, United States
| | - Rachel Akintayo
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amir-Ala Mahmoud
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - James E Fanning
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose A Foppiani
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Amitai S Miller
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan P Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Ferri A, Perlangeli G, Zito F, Ferrari S, Bianchi B, Arcuri F, Poli T. Technical refinements of the scapular tip-free flap for mandibular reconstruction. Microsurgery 2024; 44:e31176. [PMID: 38553855 DOI: 10.1002/micr.31176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/07/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND The use of scapular tip chimeric free flaps (STFFs) for reconstructing mandibular defects has recently become popular, but its utility relative to other bone-containing free flaps remains debatable. The aim of the report is to describe how technical modification of STFF impacted in its use for mandibular reconstruction also commenting results obtained in a unicentric series of patients. PATIENTS AND METHODS Patients undergoing mandibular reconstruction using an STFF from January 1, 2014 to June 1, 2022 were retrospectively enrolled in this report. We collected data on chimeric flap type, bone management, vascular pedicles, and the final outcomes. In total, 31 patients (13 men and 18 women) with a mean age of 68 years were enrolled. According to the classification system of Urken, 15 patients had body defects, while 7 had ramus defects, another 7 had symphysis defects, and 2 had both ramus and bodily defects. STFF was always harvested working in two equips simultaneously, in supine position. Dissection included preparation of chimeric components of the flap as latissimus dorsi, serratus and scapular tip. After pedicle dissection scapular bone was cut basing on reconstructive needing with a rectangular (stick) shape including the border of the scapula. In cases of longer bone harvesting, circumflex pedicle was also included to perfuse the upper portion of the scapular border. In five cases, the STFF was harvested with only the scapular angle component, and was thus a composite osteomuscular flap; for the remaining 26 cases, a chimeric STFF was used. Circumflex pedicle was included for eight patients. Six of the seven patients with symphyseal defects underwent a single osteotomy. RESULTS The average length of the harvested was 69.92 mm (maximum length = 104 mm). The average height of transplanted bone was 26.78 mm (maximum height = 44.2 mm). Mouth-opening was normal in 25 patients, limited in 6 patients, and severely impaired in no patients. The cosmetic results were rated as excellent by 20 patients, good by 8 patients, and poor by 3 patients. CONCLUSION The STFF is an excellent option for mandibular reconstruction when other flaps are not available and for patients in poor general condition. Technical innovations here presented made possible to harvest long bone segments with accurate shape thanks to osteotomies if needed and with adequate soft tissues components of the chimeric flap, ensuring satisfactory functional and cosmetic results.
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Affiliation(s)
- Andrea Ferri
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Giuseppe Perlangeli
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Francesca Zito
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Silvano Ferrari
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
| | - Bernardo Bianchi
- Operative Unite of Maxillo-Facial Surgery, Hospital of Genova, Genoa, Italy
| | - Francesco Arcuri
- Operative Unite of Maxillo-Facial Surgery, Hospital of Genova, Genoa, Italy
| | - Tito Poli
- Operative Unite of Maxillo-Facial Surgery Head and Neck Department, University of Parma, Parma, Italy
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Imaue S, Osada R, Heshiki W, Sekido K, Zukawa M, Fujiwara K, Tomihara K, Noguchi M. Presurgical imaging of the subscapular artery with three-dimensional-computed tomography angiography: Application to harvesting subscapular system free-flaps. Clin Anat 2024; 37:161-168. [PMID: 37158665 DOI: 10.1002/ca.24053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
A subscapular system free-flap is extremely useful for maxillofacial reconstruction since it facilitates the simultaneous harvesting of multiple flaps using one subscapular artery (SSA) alone. However, cases of aberrations in the SSAs have been reported. Therefore, the morphology of SSA needs to be confirmed preoperatively before harvesting the flaps. Recent developments in imaging, such as three-dimensional (3D) computed tomography angiography (3D CTA), facilitate obtain high-quality images of blood vessel images. Therefore, we examined the utility of 3D CTA in navigating the course of the SSA before harvesting subscapular system free-flaps. We examined the morphology and aberrations of the SSA using 39 sides of the 3D CTA data and 22 sides of Japanese cadavers. SSAs can be classified into types S, I, P, and A. Type S SSAs are significantly long (mean length = 44.8 mm). Types I and P SSAs have short mean lengths, measuring ≤2 cm in approximately 50% of cases. In type A, the SSA is absent. The frequency of types S, I, P, and A SSAs were 28.2%, 7.7%, 51.3%, and 12.8%, respectively. Type S can be advantageous for harvesting the SSA in subscapular system free-flaps, because it is significantly longer. In contrast, types I and P might be dangerous because their mean lengths are shorter. In type A, caution is needed not to injure the axillary artery because the SSA is absent. When surgeons need to harvest the SSA, presurgical 3D CTA is recommended.
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Affiliation(s)
- Shuichi Imaue
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
| | - Ryusuke Osada
- Department of Orthopedic Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
- Department of Orthopedic Surgery, Itoigawa Sogo Hospital, Itoigawa, Nigata, Japan
| | - Wataru Heshiki
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
- Department of Oral and Maxillofacial Surgery, Naha City Hospital, Naha, Okinawa, Japan
| | - Katsuhisa Sekido
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
- Department of Oral and Maxillofacial Surgery, Toyama Red Cross Hospital, Toyama, Toyama, Japan
| | - Mineyuki Zukawa
- Department of Orthopedic Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
| | - Kumiko Fujiwara
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
- Department of Dentistry and Oral Surgery, Division of Medicine for Function and Morphology of Sensory Organs, Faculty of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kei Tomihara
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
- Divisions of Oral and Maxillofacial Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Makoto Noguchi
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Toyama, Japan
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Molteni G, Gazzini L, Sacchetto A, Nocini R, Comini LV, Arietti V, Locatello LG, Mannelli G. Mandibular reconstruction in head and neck cancer: which is the gold standard? Eur Arch Otorhinolaryngol 2023; 280:3953-3965. [PMID: 37269408 DOI: 10.1007/s00405-023-08050-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The aim of this study is to perform a systematic review to compare the outcomes of the different surgical options for mandibular reconstruction in head and neck cancer. MATERIAL AND METHODS 93 articles were selected. Four groups were identified: titanium plate without flaps, titanium plate covered by soft tissue flap, bone tissue flaps and double flaps. We compared patients' characteristics, site of mandibulectomy, type of reconstruction and complications. RESULTS 4697 patients were reported. The groups were not homogeneous regarding the type of defect and the treatment history. A significant difference in terms of post-operative complications was found between group 1 and group 2 (p < 0.00001), and between group 2 and group 3 (p < 0.00001). Total complications rate for group 4 was significantly higher when compared to group 3 (p < 0.00001), but no significant difference was found with group 2. CONCLUSION These results suggest that mandibular reconstruction using a microvascular bone flap is the best surgical option in patients without significant comorbidities.
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Affiliation(s)
- Gabriele Molteni
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Head and Neck Department, University Hospital of Verona, Verona, Italy
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Luca Gazzini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Otorhinolaryngology-Head and Neck Surgery Department, San Maurizio Hospital, Bolzano, Italy
| | - Andrea Sacchetto
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria.
- Department of Otolaryngology, Ospedale San Bortolo, AULSS 8 Berica, Vicenza, Italy.
| | - Riccardo Nocini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Lara Valentina Comini
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Otorhinolaryngology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Valerio Arietti
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Surgery, Dentistry and Pediatrics, University of Verona, Verona, Italy
| | - Luca Giovanni Locatello
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Otorhinolaryngology, Sant'Antonio Abate Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Tolmezzo, Italy
| | - Giuditta Mannelli
- Young Confederation of European ORL-HNS, Y-CEORL-HNS, Vienna, Austria
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Jelovac D, Micic M, Hajdarevic S, Kuzmanovic C, Cukic B, Stefanovic B, Zelic K, Bonfante E, Ewers R, Petrovic M. Immediate placement of extra-short implants in refined scapula tip microvascular free flaps: In house virtual planning and surgical technique - Proof of concept. Heliyon 2023; 9:e18021. [PMID: 37496908 PMCID: PMC10366439 DOI: 10.1016/j.heliyon.2023.e18021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/24/2023] [Accepted: 07/05/2023] [Indexed: 07/28/2023] Open
Abstract
Scapula tip flaps have been introduced in the literature as an ideal surgical treatment option for large defects in the horizontal plane of the maxilla. This article aims to present a unique step by step protocol for a near total maxillectomy with a pterygoid bone resection and consecutive microvascular reconstruction with a harvested scapula tip flap. The protocol includes immediate placement of extra-short implants in donor bone with the aid of Virtual Surgical Planning (VSP), and an in-house 3D printing of medical 3D models and surgical guides. So far, there has been no presented surgical technique combining immediate implant placement in the scapula region with simultaneous microvascular repair. This technique allows: tumour resection; flap harvesting; extra-short implant placements and reconstruction to be performed in one simultaneous procedure. The technique is presented with illustrations, VSP (presented on videos), radiographs, and surgical findings. We discovered that this refinement of the scapula tip surgery has enabled reconstructive procedures to be performed at the same time as implant placements, providing expedited functional and aesthetic outcomes in selected cases. Moreover, modification of the surgical technique could enhance the competence of the oropharyngeal edge. In conclusion, this new surgical protocol utilizing VSP, 3D models and simultaneous extra-short implant placement provides indispensable advantages for such a complicated surgical procedures, while significantly shortening the duration of surgery.
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Affiliation(s)
- Drago Jelovac
- Clinic for Maxillofacial Surgery, School of Dental Medicine, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
| | - Milutin Micic
- Faculty of Medicine, Center of Bone Biology, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
| | - Sanela Hajdarevic
- Clinic for Maxillofacial Surgery, School of Dental Medicine, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
| | - Cedomir Kuzmanovic
- Clinic for Maxillofacial Surgery, School of Dental Medicine, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
| | | | | | - Ksenija Zelic
- Faculty of Medicine, Center of Bone Biology, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
- School of Dental Medicine, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
| | - E.A. Bonfante
- Department of Prosthodontics and Periodontology, University of São Paulo – Bauru School of Dentistry, Bauru, SP, Brazil
| | - Rolf Ewers
- University Hospital for Cranio Maxillofacial and Oral Surgery, Medical University of Vienna, Waehringer Guertel 18 - 20, 1090, Vienna, Austria
| | - Milan Petrovic
- Clinic for Maxillofacial Surgery, School of Dental Medicine, University of Belgrade, Dr Subotica 4, 1100, Belgrade, Serbia
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